Journal Article > Study

Prior research has shown that patients with limited health literacy are at increased risk for misunderstanding the appropriate dosing of acetaminophen, a commonly used nonprescription medication that can cause acute liver failure after an overdose. In this study, researchers examined the risk of nonprescription acetaminophen misuse among 500 English-speaking patients across 4 outpatient clinics. They found that 39% of participants had limited health literacy and 54% had low visual acuity. Both reduced visual acuity and lower health literacy were independent risk factors for dosing errors and for insufficient understanding regarding the simultaneous use of multiple acetaminophen-containing products. An AHRQ Literacy Toolkit is available that provides a business case for interventions, educational tools, and guides for engaging patients in health literacy discussions. A previous WebM&M commentary discussed an incident involving confusion with acetaminophen dosing.

Journal Article > Study

Medication management in outpatient settings requires patients to recognize adverse medication effects. This expert review study found that standardized information from a large Canadian retail pharmacy lacked key information about possible adverse effects and drug interactions. The authors suggest that this information gap leads to an urgent and addressable patient safety risk.

Journal Article > Study

Misinterpretation of medication labels is a well-recognized source of medication error in the outpatient setting, especially among patients with low health literacy. This randomized controlled study looked at how units of measurement on medication labels and dosing tool characteristics affected dosing errors with regard to liquid medications in pediatrics. About 84% of parents made at least one dosing error, and 21% made at least one large error, defined as administering more than double the dose. Researchers concluded that the use of oral syringes resulted in fewer dosing errors than cups, especially when administering small doses. The authors conclude that oral syringes should be recommended when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error.

Tools/Toolkit > Fact Sheet/FAQs

Patient Guide. Rockville, MD: Agency for Healthcare Research and Quality, Bethesda, MD: National Council on Patient Information and Education; July 2015. AHRQ Publication No. 11-0049-A.

This Web site assists consumers in learning how to take medications safely. The materials answer common questions about medication use and includes forms and a wallet card for tracking relevant information. The material is available in both English and Spanish.

Tools/Toolkit > Fact Sheet/FAQs

This AHRQ brochure provides practical advice for patients facing non-emergent surgery, to help them be generally informed about the procedure, aware of the risks, and prepared to contribute to the safety of their experience.

Journal Article > Study

Overdose of acetaminophen—a commonly used over-the-counter medication—is the leading cause of acute liver failure in the United States, with the majority of cases being unintentional. Prior studies have shown that patients with limited health literacy frequently misunderstand dosing instructions for prescription medications, and this study examined the frequency with which adult patients misunderstood dosing instructions for acetaminophen. Patients were provided with actual bottles of medications and asked to demonstrate how many pills they could take during a day, alone or in combination with other analgesics. Under these simulated conditions, nearly half the patients would have overdosed either by exceeding the recommended daily dose of acetaminophen or by combining two acetaminophen-containing products. An AHRQ WebM&M commentary discusses a case of liver injury caused by incorrect dosing of acetaminophen.

Audiovisual > Audiovisual Presentation

This video reports on a sampling of prescriptions from major retail pharmacies that demonstrated gaps, inconsistencies, and lack of clarity in drug information distributed to patients with their medications.

Newspaper/Magazine Article

This newspaper article reports on factors contributing to the increasing number of consumer medication errors, including low literacy and confusing instructions, and discusses steps being taken to prevent such errors.